CONFIDENTIAL
UNIVERSITY OF ILLINOIS EXTENSION 4-H PROGRAM
YOUTH EMERGENCY MEDICAL INFORMATION
EVENT: ____Grow Science in your 4-H Food & Nutrition Projects workshops (June 10, 11 & 12, 2013)____
PARTICIPANT'S NAME: _________________________________________________________________
Address: ________________________________________________________________________________
Street
City
State/Zip Code
Age: ____________
Sex: ________________
Date of Birth: __________/________/_________
PARENT/GUARDIAN/OTHER EMERGENCY CONTACTS:
Name: __________________________________________________________________________________
Relationship
Home Phone: _(______)_________-______________ Work Phone: _(______)_________-______________
Cell Phone:
_(______)_________-______________
Address: ________________________________________________________________________________
Street
City
State/Zip Code
Name: __________________________________________________________________________________
Relationship
Home Phone: _(______)_________-______________ Work Phone: _(______)_________-______________
Cell Phone:
_(______)_________-______________
Address: ________________________________________________________________________________
Street
City
State/Zip Code
HEALTH INFORMATION STATEMENT
Check below any information you feel staff and/or volunteers may need, to maximize the safety and the well
being of the exhibitor or staff member. To the right of the condition statement is space for more information
relating to the condition checked. Please be specific. In case of emergency, this health information may be
the only source of accurate, important information.
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Nervous or Mental (epilepsy, emotional stress, convulsions) _________________________________
_________________________________________________________________________________
Lung Disease (asthma, persistent cough, tuberculosis) ______________________________________
_________________________________________________________________________________
Disease of Heart or Blood Vessels, Increased or Abnormal Blood Pressure______________________
_________________________________________________________________________________
Pain in Chest or Shortness of Breath (heart murmur, rheumatic fever) _________________________
_________________________________________________________________________________
Stomach or Intestinal Trouble (ulcers, gall bladder or liver disorder, jaundice, hernia, colitis)
_________________________________________________________________________________
Arthritis, Diabetes, Kidney or Bladder Disease ___________________________________________
_________________________________________________________________________________
Hay Fever or Allergies ______________________________________________________________
_________________________________________________________________________________
Allergy to Medicines (including penicillin, tetanus) ________________________________________
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CONFIDENTIAL
_________________________________________________________________________________
Impaired Sight or Hearing, Chronic Ear Infections_________________________________________
_________________________________________________________________________________
Recent Surgical Operation, Accidents or Injuries_______________________________________
______________________________________________________________________________
Any Infectious Disease___________________________________________________________
______________________________________________________________________________
Skin Disease____________________________________________________________________
______________________________________________________________________________
Allergy to Foods________________________________________________________________
______________________________________________________________________________
Currently taking Medicines (list names & doses) _______________________________________
______________________________________________________________________________
Medication that needs refrigeration _________________________________________________
______________________________________________________________________________
Under on-going care of a Physician (NAME & PHONE #) for chronic or recurring problem
______________________________________________________________________________
Do you wear glasses? YES[ ] NO [ ]
SOMETIMES[ ]
Do you wear contact lenses?
YES [ ] NO[ ]
SOMETIMES [ ]
Date of last TETANUS BOOSTER_________________________________________________________
Date of last FLU SHOT __________________________________________________________________
Significant Orthopedic and/or Neuromuscular Impairment (e.g. loss of limb, spinal cord injury)
______________________________________________________________________________________
Primary Care Physician: _______________________________________________________________________
Clinic/Hospital Affiliation: _______________________________________________________________________
City: _____________________________State: ______________Phone: _(____)_____-______________________
Health Insurance Provider: _____________________________________________________________________
Owner's Name: ____________________________________ ID/Policy Number: ___________________________
Medical Privacy Statement: It is the policy of University of Illinois Extension 4-H Youth Development Programs to keep any medical
information it may have regarding 4-H Youth Development program participants confidential. However, there may be time in which such
medical information will be needed and may need to be shared with others. Examples of sharing might include: providing information to medical
personnel in the event of an emergency so that a youth may be treated; providing information to Extension staff or volunteers who are
coordinating specific events in the case of a request for reasonable accommodation; and providing information to chaperones or host families
who are responsible for the health and safety of program participants at a specific event. Except in the case of emergency, prior to sharing any
medical information, it may have with those external to the University, Extension, or 4-H, every effort will be made to get the permission of the
program participant or parent or guardian.
As a parent or guardian, I understand that if a serious illness/injury develops, medical or hospital care will be given.
I further understand that in case of serious illness/injury, I will be notified. However, if it is impossible to contact
me, I give my permission for emergency treatment, x-ray or surgery, as recommended by an attending physician.
I also understand that any accident insurance in effect (IF PROVIDED) for the event does not cover pre-existing
conditions or self-inflicted injuries.
SIGNED:____________________________________________________ DATE:__________________________
Parent or Guardian
Revised 7/03
Issued in furtherance of Cooperative Extension Work, Acts of May 8 and June 30, 1914, in cooperation with the U.S. Department of Agriculture,
D. R. Campion, Director, University of Illinois Extension, University of Illinois at Urbana-Champaign. University of Illinois Extension provides
equal opportunities in programs and employment. *The 4-H Name and Emblem are Protected Under 18 U.S.C. 707.